Consent to Treatments

Please read this carefully before you sign the consent form with our practitioners 

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I (or the substitute decision-maker listed below) consent to have my practitioner to perform the following treatment on me: Acupuncture, Cupping, Scraping, Moxibustion, Chinese Herb, Acupressure/Tuina Massage, Chinese Medicine Dietary and Exercise.

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I acknowledge that I have been informed about potential reactions that may occur during or after treatment, including but not limited to: (1) Acupuncture: Temporary soreness, bruising, light bleeding at the needle insertion points; (2) Cupping Therapy: Temporary bruising, redness, skin irritation, or in rare cases, blisters at the cupping site; (3) Moxibustion (Moxa): Mild heat sensation, redness, or in rare cases, slight burns or skin irritation; (4) Massage Therapy: Temporary soreness, redness, or mild bruising in treated areas. I understand that these reactions are generally mild and temporary, and I agree to inform the practitioner if I have any concerns during or after the treatment; (5) Scraping Therapy (Gua Sha): Redness, temporary bruising, and tenderness in the treated areas; (6) Bloodletting Therapy: Light bleeding, bruising, and temporary soreness at the treated area.

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I acknowledge that my practitioner cannot guarantee the results of the proposed treatment.

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I acknowledge that I have informed the practitioner about my relevant health history, including whether I have any allergies, metal implants, if I suffer from any type of major bleeding disorder, if I use a pacemaker, or if I have any infectious viruses or diseases.

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I understand that I have the right to withdraw my consent to the treatment at any time. I understand that the fees charged for my treatment are not covered under OHIP. I am responsible for the full and prompt payment after services received. I acknowledge that I know the applicable fees.

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I understand and consent that the therapist may need to touch and do treatment on buttocks for problem at lower back area. I understand that other sensitive area includes upper and inner thigh, penis, vagina, breasts, chest wall muscle and need my consent to do treatment on those areas.

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I understand that the practitioner will explain the following to me when I am in the clinic before the treatment, and I can ask any questions I may have: (1) the specific treatment or specific plan of treatment including sensitive areas if needed; (2) the nature of the treatment set out above; (3) the expected benefits of the treatment; (4) the material risks of the treatment; (5) the material side effects of the treatment; (6) alternatives to have the treatment; (7) the likely consequences of not having the treatment.

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